Ann Thorac Surg 2005;80:1103-1105
© 2005 The Society of Thoracic Surgeons
Case report
Adhesiolysis is Facilitated by Robotic Technology in Reoperative Cardiac Surgery
Timothy P. Martens, MD
*
,
Jeffrey A. Morgan, MD,
Marco M. Hefti, BA,
David A. Brunacci, BS,
Faisal H. Cheema, MD,
Satish K. Kesava, MD,
Steve Xydas, MD,
Nick C. Dang, MD,
Deon W. Vigilance, MD,
Takushi Kohmoto, MD,
Lyall A. Gorenstein, MD,
Craig R. Smith, Jr, MD,
Michael Argenziano, MD
Department of Surgery, Columbia University, College of Physicians and Surgeons, New York, New York
Accepted for publication March 8, 2004.
* Address reprint requests to Dr Martens, Columbia University, College of Physicians and Surgeons, 17-415, 630 W 168 St, New York, NY10032; (Email: tpm2102{at}columbia.edu).
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Abstract
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Over a 2-year period, 5 patients who required reoperative chest surgery underwent robotic adhesiolysis with the da Vinci (Intuitive, Sunnyvale, CA) system. Resternotomy was performed under direct visualization for coronary revascularization (n = 2) or valve replacement (n = 1). A fourth patient required coronary revascularization after a previous axilloaxillary bypass. The final case involved the preparation of a substernal pathway for a gastric pull-up. In all cases adhesions were taken down without injury to the underlying structures. All grafts were preserved, and all patients recovered uneventfully. Robotic adhesiolysis is a versatile technique that allows careful lysis of adhesions and minimizes the risk of major complication during reoperative chest surgery.
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Introduction
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Resternotomy for reoperative cardiac surgery has become increasingly common with an aging patient population. In addition to the increased time and care required for dissection of adhesions, resternotomy is associated with increased morbidity and mortality [1]. This is particularly true for patients more than 70 years old; patients with a history of mediastinitis, sternal wound infection, or multiple previous surgeries; and patients with an enlarged heart [1]. Patent grafts from previous bypass surgery are particularly vulnerable to inadvertent division, with often disastrous consequences.
Several techniques have been described to minimize the risks of resternotomy. One approach is to use alternative incisions. Valve reoperations have been performed through parasternal approaches [2], and both valve and coronary artery bypass grafting (CABG) reoperations have been done through thoracotomies [3, 4]. However, all of these approaches provide limited exposure and are often not suitable for performing complex or multiple procedures better handled by a median sternotomy.
Anterior retraction of the sternum allows access to the retrosternal space with electrocautery and is popular with some groups [5]. Alternatively, the lower sternum can be divided and the xyphoid excised, followed by endoscopic clearance of these adhesions [6]. These methods allow dissection of retrosternal adhesions under direct vision. However, they provide a limited field of view for dissection and do not adequately expose or protect underlying structures.
Here we report on the use of the da Vinci (Intuitive, Sunnyvale, CA) robotic operating system in 5 patients who were undergoing chest reoperations. In each case the robot was used to clear adhesions from previous operations without injury to the heart or previous bypass grafts. In addition to clearing adhesions, the robot was used to accomplish internal mammary artery (IMA) takedown in 3 patients. Surgery was completed successfully in all 5 patients with no adverse events.
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Case Reports
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During the past 2 years, 5 patients have undergone robotic chest reoperations at Columbia University, College of Physicians and Surgeons, for repeat CABG (n = 2), combined CABG and aortic valve replacement (AVR) (n = 1), isolated AVR (n = 1), and gastric pull-up (n = 1). Three patients had existing patent grafts: left IMA (LIMA) to left anterior descending in 2 patients, and axilloaxillary bypass in 1 patient. In all cases the robot was used to clear adhesions under direct vision, thus reducing the risk of resternotomy. In addition the robot was also used successfully to perform an IMA takedown in the 3 patients who required revascularization.
The daVinci system consists of a camera and two arms with fully articulated wrists, all of which are controlled by a surgeon at a remote console. The wrists have full range of motion with 6 degrees of freedom, and the binocular camera allows stereoscopic vision through a pair of monitors in the surgeon’s console. A double-lumen endotracheal tube was placed in each patient, and its position was confirmed bronchoscopically before the start of the procedure.
After successful single-lung ventilation, the camera port was bluntly inserted into the pleural space. This was accomplished through a 1-cm incision in the left or right fifth intercostal space, 2 cm anterior to the anterior axillary line. Separate incisions were then made in the third and sixth intercostal spaces slightly anterior to the camera port incision. The right and left arms of the robotic system were then inserted sequentially under direct vision. Once adhesions were cleared and other necessary interventions performed, the remainder of the procedure was performed through a resternotomy (3 patients), clamshell incision (1 patient) or abdominal midline and neck incisions (1 patient). Mean bypass time was 107 minutes, mean cross-clamp time was 68 minutes, and mean operating room time was 459 minutes. Patients remained in the intensive care unit for an average of 36 hours and in the hospital for 8 days.
Patient 1
This 66-year-old man had undergone a CABG in 1987 and had required operative revascularization. Preoperative cardiac catheterization revealed a patent LIMA graft and an occluded saphenous vein graft. A trocar was bluntly inserted into the right side of the chest through a 1-cm incision in the fifth intercostal space. The insertion of the robotic endoscopic camera through this trocar then allowed positioning of the instrument arms under direct vision through 1-cm incisions in the third and sixth intercostal spaces. The soft tissues posterior to the sternum were dissected free by using cautery, exposing all but the two manubrial sternal wires (Fig 1) and the left pleural space up to the second interspace. The right IMA (RIMA) was taken down over a similar distance. The instrument arms were then removed and the sternum divided under direct vision through the robotic camera. The previous LIMA graft was preserved, and the patient had an uneventful recovery.
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Fig 1. Intrathoracic view from the daVinci (Intuitive, Sunnyvale, CA) camera showing a sternal wire being removed after retrosternal adhesions had been cleared with robotic assistance.
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Patient 2
This 83-year-old man presented for reoperative CABG/AVR. A preoperative angiogram revealed a patent LIMA adhesed to the sternum and two patent saphenous vein grafts. Access to the right pleural space was obtained as described previously. The retrosternal adhesions were taken down, and the LIMA graft was dissected free from the posterior sternal surface by using DeBakey forceps and scalpel cautery. Dissection continued until the posterior sternal surface was clearly visible and free of adhesions from the manubrium to the xyphoid process. CABG and AVR were then performed through a conventional resternotomy without difficulty.
Patient 3
A 72-year-old man with a previous axilloaxillary bypass was scheduled for CABG. The left pleural space was entered through port incisions in the third, fifth (camera port), and sixth intercostal spaces and the LIMA was dissected from the chest wall as far proximally as the subclavian vein without disruption of the previous bypass graft. Distally, the IMA was dissected free to the sixth intercostal space, just proximal to its bifurcation. CABG was then completed through a clamshell incision.
Patient 4
A 37-year-old man with a previous sternotomy for a mitral valve repair underwent reoperative aortic valve replacement. The da Vinci robotic system was inserted into the right side of the chest as described for the first two patients and was used to lyse anterior mediastinal adhesions. This was followed by an uneventful resternotomy and the replacement of the artificial valve. The patient had an unremarkable postoperative course.
Patient 5
This 64-year-old woman underwent AVR complicated by esophageal perforation that required esophageal resection. The patient was discharged home and later readmitted for gastric pull-up. The da Vinci robot was used to prepare a retrosternal path for the pull-up without sternotomy. The robotic camera was bluntly inserted through a 1-cm incision in the left fifth intercostal space, 2 cm anterior to the anterior axillary line. The robotic arms were then inserted under direct vision through the third and sixth intercostal spaces slightly anterior to the camera port site. The lung-to-chest-wall adhesions were dissected free, allowing further medial dissection of adhesions between the heart, aorta, and sternum. The dissection was carried out until a large space was present for the gastric pull-up.
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Comment
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The robot was used successfully in all patients with no intraoperative or postoperative complications. The subsequent open surgery was performed without difficulty in all patients, and all made an uneventful postoperative recovery. All patent vascular grafts were preserved. All patients had uneventful postoperative courses and made complete recoveries.
Adhesions are a major cause of complications in cardiac reoperations, potentially leading to cardiac injury or fatal hemorrhage. Although techniques such as sternal retraction and endoscopic assistance help reduce the complication rate, they are limited to direct vision of retrosternal adhesions. The da Vinci robot allows for the clearance of any intrathoracic adhesion, including those that cannot be visualized with alternative techniques. In addition the articulating robot arms provide greater flexibility and finer control than is possible with conventional instruments. Although the learning curve for use of the robot is considerable, this report demonstrates that once proficiency is attained, the robot can be successfully used to reduce the risks inherent in cardiac reoperations. This report also outlines additional applicability of robotic technology to cardiac surgical procedures, aside from the relatively well-described applications, such as totally endoscopic CABG [7], atrial septal defect repair [8], and robot-assisted mitral valve repair [8].
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References
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- Morishita A, Shimakura T, Miyagishima M, et al. Minimally invasive direct redo coronary artery bypass grafting Ann Thorac Cardiovasc Surg 2002;8(4):209-212.[Medline]
- Adams DH, Filsoufi F, Byrne JG, Karavas AN, Aklog L. Mitral valve repair in redo cardiac surgery J Card Surg 2002;17(1):40-45.[Medline]
- Eddy AC, Miller D, Johnson D, et al. Anterior sternal retraction for reoperative median sternotomy Am J Surg 1991;161(5):556-559.[Medline]
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- Argenziano M, Oz MC, Takushi K, et al. Totally endoscopic atrial septal defect repair with robotic assistance Circulation 2003;108(suppl II):II-91-II-194.
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Abstract
Introduction
